24. CONNECT offers many services: How interested are you in achieving each of the following?

Not Currently Interested

Somewhat Interested

Interested

Very Interested

Get more education

Get better or more affordable housing

Improve my English skills

Fix my credit or save more money

Get a new or better job

24b. What
is your monthly household income? Please estimate your TOTALmonthly income for all household
members.(The total amount your family
has available to pay for bills during the month)

25. What is your employment status?

Working one full time job (35+ hours per week)Working one part-time jobWorking more than one jobI am currently not working

How much do you currently earn from your job(s), before taxes?

$

per

HourWeekMonthYear

25b. How many hours do you currently work in a typical week?

25c. You have indicated that you're not interested in finding a job, and you're not currently employed. Can you tell us a little more about why you're not currently interested in looking for a job?

I am disabled or unable to workI'm retiredI'm discouraged, and haven't been able to find workI'm not interested in being employed

26. How would you describe your housing situation?

I have a satisfactory housing situationI would like to change my housing situation I am worried about losing my house or apartment in the next 30 daysI am homeless

26b Have you moved in the last 6 months?

YesNo

You have indicated that you are concerned about your housing situation or are homeless. By providing us with the following information, we can assess whether you might be eligible for monetary assistance called RAFT (Residential Assistance for Families in Transition). You can always choose to not answer a question if you are uncomfortable.

Do you have a lease or a signed contract with the owners of your residence which states how much rent you will pay and for how long you will pay that amount?

YesNo

Are you currently pregnant?

YesNo

Do you have any children living with you who are 21 or younger?

YesNo

How old is your youngest child?

Please enter the child's age in years. Enter 0 for children who have not had their 1st birthday.

Have you ever had or currently have an active DCF (Department of Children and Families) case for any of your children?

YesNo

Have any of your children ever been placed in foster care?

YesNo

In the past year, how many times has your family moved due to economic reasons?

Since the age of 18, have you ever stayed in a homeless shelter or domestic violence shelter in Massachusetts?

YesNo

27. Do you currently receive housing assistance (a voucher or public housing)?

30. If you had no income, how long could you pay your bills using your savings?

I have no savingsLess than 1 monthBetween 1 and 3 monthsMore than 3 monthsI don't know

31. Do you agree with the following statement? I am comfortable dealing with my day-to-day financial matters such as checking accounts, credit cards and tracking expenses.

Strongly AgreeSomewhat AgreeSomewhat DisagreeStrongly Disagree

32. Do you agree with the following statement? I am confident I can make progress toward achieving my financial goals.

Strongly AgreeSomewhat AgreeSomewhat DisagreeStrongly Disagree

33. In the last 3 months, how many times have you paid a late fee on a bill or loan?

I have not paid a late fee in the last 3 monthsOnceTwiceThree or more times

34. Please select the statement that best describes your spending habits over the past three months (please do not include large purchases such as a house or car).

My spending is less than my income (I am able to save money)My spending is equal to my incomeMy spending is a little more than my income (I am losing a little money)I am spending much more than my income (I am losing a lot of money)I don't know or I am not sure

36. In the last three months, have you set aside money for savings?

YesNoDon't know

37. In the last three months, have you set a monthly budget and kept it?

YesNoDon't Know

39. Does your family currently use any of the following?

Yes

No

Don't Know

SNAP (also known as "food stamps")

MassHealth/Health Connector

WIC Assistance (Women, Infants and Children)

TANF (Welfare)

40. What best describes your citizenship status?

US CitizenGreen card holder for less than 5 yearsGreen card holder for 5 or more yearsRefugeeTemporary Protected StatusOther/Prefer not to answer

41. Do you agree to allow CONNECT's partner organizations to share your information in order to provide you all the services that you are eligible for?

YesNo

42. Consent to pull credit reports

I, a participant in the CONNECT Program, authorize
The Neighborhood Developers, Inc. (TND) to request a Factual Data consolidated
tri-merge credit report. This credit
report will be provided to me at no cost on request. My electronic signature below authorizes the credit
reporting agencies to obtain information regarding my outstanding credit
accounts (mortgages, auto loans, personal loans, charge cards, credit unions,
etc.) no more than twice per year for a maximum of 5 years, or completion of the
CONNECT Financial Coaching Program if applicable. Authorization is further granted to the reporting
agencies to use a photo static reproduction of this authorization if necessary
to obtain any information regarding the above mentioned.

I understand that this credit report can be made available to me for
financial counseling purposes and to aid in my financial well-being. Additionally, I release my credit score to
TND and CONNECT for data collection and evaluative purposes. I understand that
it will be used only in the aggregate without personal identifiers and will never
be released to a third party without my consent. Any reproduction of this credit report
authorization and release made by reasonable means (e.g. photocopy or
facsimile) is considered an original.

I consent to allow TND to pull credit reportsI do not consent

Please enter your Social Security Number or individual tax ID number.

Page 3

You said that you do not want CONNECT’s five partner organizations to share your information. That means we will not be able to match you to the resources that might help you. Are you sure?

Yes, I’m sure. Do not share my answers.I changed my mind. Please match
me to all the resources that might help me.

OK, you will not be matched with any services. If you want to learn about any of our services, please talk to the receptionist at the front desk or call (617) 889-1375.